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Cash Contribution Form
Please submit a separate form for each implementing agency

1. Name of  Donor:*                   

2. Implementing  Partner:*  

3. Cash Contribution 

Total value       Currency 

Please indicate:
Contribution against 2005 Appeal              Contribution for general emergency activities

4. Sector :
Please tick  applicable sector(s) and, if available, provide allocated amount in the first box (Amount) and indicate relevant regions in the second box (Code) by using the equivalent regional codes stated here below.

Regional Codes:
Afar=1             Amhara=2       Beneshangul  Gumuz=3      Dire Dawa=4        Gambella=5      Harari=6   Oromiya=7     SNNPR=8         Somali=9                             Federal/Country Wide=10

 Amount                             Code (1, 2, 3, ...)
Health and Nutrition                                                  
Water and Sanitation                                                    
Shelter and Household Items                                    
Disaster Management and Capacity Building              
Post Emergency Recovery and Rehabilitation          
Logistics and Operational Support                               
Other relief sector                                                    

5.  Status of funding:
Please indicate status of contribution
 Pledged        Confirmed    

Contact Person

Please indicate name,  phone number and email of the person in your organization whom we can contact for contribution information

Phone Number:

*  Required Information

To ensure accurate and timely reporting on humanitarian contributions, we will be contacting you for contribution updates on a quarterly basis.